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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Notification of Other Incidents Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} complies with statutory notification requirements to the Care Quality Commission (CQC) under the Care Quality Commission (Registration) Regulations 2009 (as amended), including Regulation 16 (death of a service user), Regulation 17 (death or unauthorised absence of a detained service user under the Mental Health Act 1983 in relevant circumstances), and Regulation 18 (notification of other incidents). This policy also aligns with CQC guidance on statutory notifications and supports compliance with the Health and Social Care Act 2008 regulatory framework.

2. Scope

This policy applies to all staff, including the Registered Manager, Safeguarding Lead, and Health and Safety Lead. It covers the notification and reporting of incidents that impact the safety, health, and well-being of the people we support, staff, and others associated with our service.

This policy covers statutory notifications to the Care Quality Commission (CQC) and related external reporting duties. Statutory notifications include:

A. Regulation 18 – Notification of other incidents (must notify CQC without delay):

• Serious injury to a person using the service which meets the Regulation 18 criteria (see Section 3 – Serious Injuries).
• Any abuse or allegation of abuse relating to a person using the service.
• Any incident that is reported to, or investigated by, the police.
• Any event that prevents, or appears likely to threaten to prevent, {{org_field_name}} from carrying on the regulated activity safely or in accordance with registration requirements. This includes (but is not limited to):
  • insufficient suitably skilled staff to deliver safe care;
  • interruption of essential utilities (electricity, gas, water, sewerage) for more than 24 hours;
  • physical damage to premises which is likely to adversely affect the delivery of care;
  • failure or malfunction of fire alarms or other safety devices for more than 24 hours.
• (Where applicable) any placement of a person under 18 in an adult psychiatric unit for longer than 48 hours.
• Mental Capacity Act notifications (Regulation 18(4A) and 18(4B)): any request for a DoLS standard authorisation and any Court application relating to the deprivation of a person’s liberty, notified when the outcome is known (or when withdrawn).

B. Regulation 16 – Notification of death of a service user (must notify CQC without delay).

C. Regulation 17 – Mental Health Act notifications (only where applicable): death or unauthorised absence of a service user detained or liable to be detained under the Mental Health Act 1983 in the circumstances required by the regulation and CQC guidance.

3. Principles of Incident Notification and Management

{{org_field_name}} is committed to ensuring timely and accurate reporting of incidents to relevant authorities, as required under CQC regulations. The following principles guide our approach:

Timely Reporting of Incidents

• All reportable incidents must be notified to CQC as soon as possible, and no later than the legally required timeframe.
• Staff must immediately inform the Registered Manager of any incident that may require external notification.
• Safeguarding incidents and allegations of abuse must be notified to the Local Authority Safeguarding Adults team immediately and in line with local safeguarding procedures. Where the incident is a statutory notifiable event, the CQC notification must be submitted without delay in accordance with Regulation 18. For operational clarity, {{org_field_name}} sets an internal target of submitting the CQC notification on the same day where possible and no later than the next working day, unless exceptional circumstances apply; any delay and the reasons for it must be clearly documented.
• Deaths of individuals receiving care must be reported to CQC without delay, as per Regulation 16 (Notification of Deaths).

Types of Notifiable Incidents and Reporting Requirements

• Serious injuries (Regulation 18(2)(a) and 18(2)(b)): Notify CQC without delay where, in the reasonable opinion of a healthcare professional, an injury has resulted in (or requires treatment to prevent) any of the following outcomes:
  • non-temporary impairment of sensory, motor or intellectual function (including where it has lasted or is likely to last 28 days or more);
  • changes to body structure;
  • prolonged pain or prolonged psychological harm (a continuous period of 28 days or more); or
  • shortening of life expectancy.

Examples (non-exhaustive) may include significant injuries affecting major organs, bones, muscles, joints or blood vessels; pressure ulcers grade 3 or above that develop after admission; or psychological harm requiring clinical intervention (for example PTSD, clinical depression or clinical anxiety).
RIDDOR reporting is separate and must be completed where the incident meets RIDDOR criteria.

• Abuse or allegation of abuse (Regulation 18(2)(e)): Notify CQC without delay of any abuse or allegation of abuse relating to a person using the service. This must be accompanied by immediate safeguarding action and referral to the Local Authority Safeguarding Adults team in line with local safeguarding procedures.
• Police involvement (Regulation 18(2)(f)): Notify CQC without delay of any incident that is reported to, or investigated by, the police in connection with the service or a person using the service.
• Infectious disease outbreaks / public health incidents: {{org_field_name}} will follow current UK public health arrangements (including the UK Health Security Agency (UKHSA) and the local Health Protection Team) and local infection prevention and control (IPC) procedures when managing and reporting outbreaks.

A CQC notification is required where the outbreak or the associated control measures meet the Regulation 18(2)(g) threshold, meaning the event prevents, or appears likely to threaten to prevent, the service from carrying on the regulated activity safely or in accordance with registration requirements (for example where staffing levels, safe care delivery, or the environment are significantly compromised).

• Fire, Flood, or Significant Property Damage: Any significant damage that disrupts the provision of care must be reported to CQC, as well as local emergency services if necessary.
• Missing person / unauthorised absence: Where a person goes missing, staff must take immediate action in line with {{org_field_name}}’s missing person procedure, including safeguarding actions and contacting the police where appropriate.

CQC statutory “unauthorised absence” notifications apply primarily to people detained or liable to be detained under the Mental Health Act 1983 in the circumstances described in Regulation 17 and relevant CQC guidance. Where Regulation 17 applies to {{org_field_name}}, the Registered Manager (or delegated senior) will submit the required notification to CQC without delay.

• Events that threaten service continuity / safe running (Regulation 18(2)(g)): Notify CQC without delay of any event that prevents, or appears likely to threaten to prevent, {{org_field_name}} from carrying on the regulated activity safely or in accordance with registration requirements. This includes (as set out in the regulation): insufficient suitably skilled staff, loss of essential utilities for more than 24 hours, physical damage to premises likely to adversely affect care, and fire alarm or safety device failure for more than 24 hours. Other serious disruptions (for example major IT outages, flooding, loss of heating, or significant environmental hazards) must be assessed against this statutory test and notified where the threshold is met.

Mental Capacity Act notifications (Regulation 18(4A) and 18(4B))

{{org_field_name}} must notify CQC of:

1. any request to a supervisory body for a DoLS standard authorisation (Schedule A1 Mental Capacity Act 2005); and
2. any application to the Court in relation to depriving a person of their liberty under section 16(2)(a) of the Mental Capacity Act 2005.

Timing: the notification must be submitted once the outcome is known or, if the request/application is withdrawn, at the point of withdrawal.

The notification must include:

• the date and nature of the request/application;
• whether an urgent authorisation was used (where relevant);
• the outcome (or reason for withdrawal); and
• the date of outcome/withdrawal.

Duty of Candour and Open Communication

• In line with Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Duty of Candour), we maintain an open and transparent approach when reporting incidents.
• Families, advocates, and relevant stakeholders are informed of any incidents that affect individuals in our care.
• A formal apology and explanation is provided to the affected individual or their representative where harm has occurred.

Incident Investigation and Root Cause Analysis

• All notifiable incidents are investigated thoroughly by the Registered Manager, Health and Safety Lead, or Safeguarding Lead, as applicable.
• Root Cause Analysis (RCA) is conducted for all major incidents to determine the underlying causes and prevent recurrence.
• Findings are documented, and lessons learned are shared with staff to enhance service safety and quality.

Record-Keeping and Documentation

• All incidents must be recorded in an Incident Log, detailing the nature of the incident, actions taken, and notifications made.
• Copies of notifications submitted to CQC must be retained for compliance and audit purposes.
• Staff are required to complete detailed incident reports within 24 hours of the event occurring.

Training and Staff Responsibilities

• All staff receive mandatory training on incident recognition, reporting, and duty of candour.
• The Registered Manager is responsible for ensuring all CQC notifications are made in a timely and accurate manner.
• The Safeguarding Lead ensures that all safeguarding-related incidents are reported to local authorities and CQC.
• The Health and Safety Lead oversees the investigation of workplace injuries and environmental hazards.

Monitoring and Continuous Improvement

• Regular audits of incident reporting are conducted to ensure compliance with CQC regulations.
• Lessons learned from incidents are used to inform policy updates, staff training, and risk management strategies.
• Trends and patterns in incident data are analysed to identify areas for service improvement.
• A quarterly review of all incidents is conducted by management to ensure best practices are maintained.

4. Roles and Responsibilities

• Registered Manager: Ensures all notifiable incidents are reported to CQC and relevant authorities in a timely manner.
• Safeguarding Lead: Oversees reporting of safeguarding incidents and ensures appropriate referrals are made.
• Health and Safety Lead: Manages incident investigations related to workplace safety and risk management.
• All Staff: Responsible for recognising, documenting, and escalating incidents in accordance with this policy.
• Compliance Officer: Ensures adherence to regulatory reporting requirements and monitors incident trends.

5. Submitting statutory notifications to CQC (process)

Statutory notifications must be submitted using the CQC Provider Portal / CQC online notification forms in accordance with CQC notifications guidance. The Registered Manager is responsible for submission, ensuring the information provided is accurate, complete and submitted without delay, and for delegating appropriately if unavailable.

A copy of each submitted notification, confirmation of submission, and supporting evidence (for example incident report, safeguarding referral, police reference number, witness statements, and any root cause analysis) must be stored securely in line with {{org_field_name}} record-keeping requirements and made available for inspection and audit.

6. Related Policies

This policy should be read in conjunction with:

• SL11 – Safe Care and Treatment Policy
• SL13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• SL16 – Health and Safety at Work Policy
• SL20 – Duty of Candour Policy
• SL25 – Management of Accidents, Incidents, and Near Misses Policy
• SL30 – Emergency and Business Continuity Plan

7. Policy Review

This policy will be reviewed annually or sooner if legislative changes, CQC requirements, or organisational needs necessitate an update. All staff will be informed of updates to ensure continued compliance and best practices in incident notification and reporting.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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